MEDICARE: GRUPO INTENSIVO PEDIATRICO DE SAN JUAN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2080P0203X	Pediatric Critical Care Medicine Physician		PR

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	89351	OTHER	PR	TRIPLE S

General Provider Information

NPI Number	:	1477537892
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GRUPO INTENSIVO PEDIATRICO DE SAN JUAN

Provider Business Mailing Address
First Line	:	252 CALLE SAN JORGE
Second Line	:	MEDICAL OFFICE BUILDING SUITE 406
City	:	SAN JUAN
State	:	PR
Zip	:	00912-3310
Country	:	US
Telephone Number	:	787-726-0210
Fax Number	:	787-728-5136

Provider Business Practice Location Address
First Line	:	252 CALLE SAN JORGE
Second Line	:	MEDICAL OFFICE BUILDING SUITE 406
City	:	SAN JUAN
State	:	PR
Zip	:	00912-3310
Country	:	US
Telephone Number	:	787-726-0210
Fax Number	:	787-728-5136

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. JOSE R RODRIGUEZ-SANTANA
Credential	:	MD
Telephone Number	:	787-726-0210

Provider Enumeration Date	:	11/30/2005
Last Update Date	:	08/22/2020

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